<!DOCTYPE html>
<html lang="en">
<head>
    <meta charset="UTF-8">
    <title>Title</title>
    <style type="text/css">

        .my-table {
            border: 1px solid #ddd;
            border-collapse: collapse;
        }

        .my-table thead tr th,
        .my-table tbody tr td {
            border: 1px solid black;
            border-collapse: collapse;
        }

        .one-row {

        }

        .one-row tr:not(:first-child) {
            border-left: none;
        }

    </style>
</head>
<body>
<div style="width:750px">
    <table class="my-table"
           style="text-align: center;table-layout:fixed;word-break:break-all; font-size:10px;margin-left: 8px;"
           width="750" height="1050" cellspacing="0" cellpadding="0" border="0">
        <tr>
            <td colspan="24" style="border: none;">湖南省医疗保险医疗费用结算单</td>
        </tr>
        <tr>
            <td colspan="24" align="right">打印日期:2021年09月18日</td>
        </tr>
        <tr class="one-row" style="height: 45px;">
            <td colspan="7" style="border-right: none;">医疗机构名称:湖南跃进机电有限责任公司职工医院</td>
            <td colspan="5" style="border-right: none; border-left: none;">医院等级:</td>
            <td colspan="6" style="border-left: none;">就诊号:192899</td>
            <td colspan="6">金额单位：元</td>
        </tr>
        <tr>
            <td colspan="2">姓名</td>
            <td colspan="2">廖春梅</td>
            <td colspan="2">性别</td>
            <td colspan="2">女</td>
            <td colspan="2">年龄</td>
            <td colspan="2">35</td>
            <td colspan="2">个人编号</td>
            <td colspan="4">43000011100004601949</td>
            <td colspan="2">补助类别</td>
            <td colspan="4">无</td>
        </tr>
        <tr>
            <td colspan="2">单位名称</td>
            <td colspan="6">永州市名匠装饰设计工程有限公司</td>
            <td colspan="2">人员类别</td>
            <td colspan="2">11</td>
            <td colspan="2">联系电话</td>
            <td colspan="4">13001359353</td>
            <td colspan="2">公务员标志</td>
            <td colspan="4">0</td>
        </tr>
        <tr>
            <td colspan="2">住院号</td>
            <td colspan="2">73600</td>
            <td colspan="2">科室</td>
            <td colspan="2">内科</td>
            <td colspan="2">床位号</td>
            <td colspan="2">3301</td>
            <td colspan="2">入院日期</td>
            <td colspan="2">2021-09-14</td>
            <td colspan="2">出院日期</td>
            <td colspan="2">2021-09-15</td>
            <td colspan="2">住院天数</td>
            <td colspan="2">1</td>
        </tr>
        <tr>
            <td colspan="2">证件号码</td>
            <td colspan="6">431281198606062828</td>
            <td colspan="2">证件类型</td>
            <td colspan="2">01</td>
            <td colspan="4">出院诊断</td>
            <td colspan="8">霍乱</td>
        </tr>
        <tr>
            <td colspan="2">医疗类别</td>
            <td colspan="6">2101</td>
            <td colspan="2">结算时间</td>
            <td colspan="2">2021-09-15</td>
            <td colspan="2">主管医师</td>
            <td colspan="4"></td>
            <td colspan="3">个人账户余额</td>
            <td colspan="3"></td>
        </tr>
        <tr>
            <td colspan="2" rowspan="3">既往费用</td>
            <td colspan="2" rowspan="2">本年住院次数</td>
            <td colspan="2" rowspan="2">本年度分段计算费用累计</td>
            <td colspan="18">本年度已发生的住院医疗费用支出</td>
        </tr>
        <tr>
            <td colspan="2">医疗费合计</td>
            <td colspan="2">已付起付线</td>
            <td colspan="2">统筹支付</td>
            <td colspan="2">政策自费</td>
            <td colspan="2">政策自付</td>
            <td colspan="2">大额基金支付</td>
            <td colspan="2">大病保险合规费用</td>
            <td colspan="2">大病保险支付</td>
            <td colspan="2">医疗救助支付</td>
        </tr>
        <tr>
            <td colspan="2">0</td>
            <td colspan="2">基金为医院减免金的累计</td>
            <td colspan="2">0</td>
            <td colspan="2">0</td>
            <td colspan="2">undefined</td>
            <td colspan="2">0</td>
            <td colspan="2">0</td>
            <td colspan="2">0</td>
            <td colspan="2">0</td>
            <td colspan="2">0</td>
            <td colspan="2">0</td>
        </tr>
        <tr>
            <td colspan="4">收费项目类别</td>
            <td colspan="4">总费用</td>
            <td colspan="2">甲类费用</td>
            <td colspan="2">乙类费用</td>
            <td colspan="4">收费项目类别</td>
            <td colspan="4">总费用</td>
            <td colspan="2">甲类费用</td>
            <td colspan="2">乙类费用</td>
        </tr>
        <tr>
            <td colspan="4">手术费</td>
            <td colspan="4">949.3</td>
            <td colspan="2">0</td>
            <td colspan="2">0</td>
        </tr>
        <tr>
            <td colspan="4">合计</td>
            <td colspan="4">949.3</td>
            <td colspan="2">0</td>
            <td colspan="2">0</td>
            <td colspan="12"></td>
        </tr>
        <tr>
            <td colspan="4" rowspan="2">政策项</td>
            <td colspan="6">个人负担</td>
            <td colspan="6">基金支付</td>
            <td colspan="8" rowspan="2">合计</td>
        </tr>
        <tr>
            <td colspan="3">金额</td>
            <td colspan="3">个人负担比例</td>
            <td colspan="3">金额</td>
            <td colspan="3">基金支付比例</td>
        </tr>
        <tr>
            <td colspan="4">合计</td>
            <td colspan="6">0</td>
            <td colspan="6">0</td>
            <td colspan="8">0</td>
        </tr>
        <tr>
            <td colspan="4">本次医疗费总额</td>
            <td colspan="6"></td>
            <td colspan="6"></td>
            <td colspan="8"></td>
        </tr>
        <tr>
            <td colspan="4">统筹基金支付</td>
            <td colspan="6"></td>
            <td colspan="6">个人账户支付金额</td>
            <td colspan="8"></td>
        </tr>
        <tr>
            <td colspan="4">公务员补助支付</td>
            <td colspan="6"></td>
            <td colspan="6">现金支付金额</td>
            <td colspan="8"></td>
        </tr>
        <tr>
            <td colspan="4">大额基金支付</td>
            <td colspan="6"></td>
            <td colspan="6">医疗救助支付</td>
            <td colspan="8"></td>
        </tr>
        <tr>
            <td colspan="4">大病保险支付</td>
            <td colspan="6"></td>
            <td colspan="6">其他基金支付</td>
            <td colspan="8"></td>
        </tr>
    </table>
    <div id="foot" style="margin-top: 20px;">
        <span style="margin-left: 8px">患者/家属签字：</span>
        <span style="margin-left: 100px">联系电话:</span>
        <span style="margin-left: 100px">经办人:</span>
        <span style="margin-left: 100px">审核人:</span>
    </div>
</div>
</body>
</html>